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Tricuspid Intervention After Pulmonary Valve Replacement in Adult CHD
Study Questions:
What is the impact of concomitant tricuspid valve intervention (TVI) in adults with congenital heart disease (CHD) undergoing pulmonary valve replacement (PVR)?
Methods:
A multicenter, retrospective, observational study was performed. The national Canadian cohort enrolled 542 patients with tetralogy of Fallot (TOF) or pulmonary stenosis (PS) who underwent isolated PVR (66.8%) or PVR + TVI (33.2%). The primary endpoint was a composite consisting of seven early adverse events (death, re-intervention, cardiac electronic device implantation, infection, thromboembolic event, hemodialysis, and readmission). Patients were included if they had mild or greater tricuspid regurgitation (TR) prior to PVR. Comparisons between groups were made using multivariable logistic and negative binomial regression.
Results:
The median age at PVR or PVR + TVI was 35.3 years. TVI consisted of tricuspid valve repair in 91.7% and tricuspid valve replacement in 8.3% of patients. TR decreased by ≥1 echocardiographic grade in 35.4% of patients with mild TR, 66.9% of patients with moderate TR, and 92.8% of patients with severe TR. PVR + TVI was associated with an additional 2.3-fold reduction in TR grade (odds ratio, 0.44; 95% confidence interval, 0.25-0.77) without an increase in early adverse events or length of hospitalization.
Conclusions:
The authors concluded that in patients with TOF or PS and significant TR, concomitant TVI is safe and results in better early tricuspid valve competence than isolated PVR.
Perspective:
Tricuspid valve dysfunction is common in patients with congenital heart disease and pulmonary valve disease requiring intervention. When performed for pulmonary valve regurgitation, PVR generally results in a significant decrease in right ventricular dimensions, which can also lead to a decrease in severity of TR. This study demonstrated improvement in tricuspid valve function with tricuspid intervention at the time of PVR beyond that seen with PVR alone, without a cost in terms of perioperative morbidity or mortality. There was a trend towards greater need for a new pacemaker or defibrillator in patients undergoing concomitant TVI with PVR, although this did not achieve statistical significance (odds ratio, 0.72-3.06; p = 0.189). Although the long-term benefits of these interventions remain unclear, the study suggests a role for considering TVI in patients undergoing PVR with moderate or greater TR.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Implantable Devices, SCD/Ventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Interventions, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound
Keywords: Cardiac Surgical Procedures, Cardiology Interventions, Defibrillators, Echocardiography, Heart Defects, Congenital, Pacemaker, Artificial, Pulmonary Valve Insufficiency, Pulmonary Valve Stenosis, Renal Dialysis, Tetralogy of Fallot, Thromboembolism, Tricuspid Valve Insufficiency
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